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Electronic Health Record - Student Access and Use

Medical Students (M.D.)

Policy ID Number:  N\A 
Policy Title:  ELECTRONIC HEALTH RECORD - STUDENT ACCESS AND USE 
Classification:  University 
Approval Authority:  Undergraduate Curriculum Committee 
Responsible Entity:  MUSC College of Medicine – Undergraduate Medical Education 
Policy Owner:  Clinical Sciences Planning and Evaluation Committee

 

I. Policy Statement

Both the Association of American Medical Colleges and multidisciplinary Alliance for Clinical Education have recognized the important role that meaningful medical student participation in the Electronic Health Record (EHR) plays in developing core competencies necessary for patient care.[1, 2] The EHR should be included as part of medical students’ educational experience from the beginning of their training with attention to adequate preparation through the preclerkship curriculum and incorporation of institutional compliance guidelines in the clinical years.

II. Scope

This policy is intended to provide guidance to MUSC College of Medicine Faculty, Fellows, Residents and Medical Students regarding appropriate access and use for students at various levels in the MD Degree training. It does not supersede other enterprise regulatory policies. (ex. MUSC Acceptable Use of Computing and Telecommunications Resources Policy 

III. Approval Authority

The final governing committee which is responsible for approving the policy is the Undergraduate Curriculum Committee. The Clinical Sciences Planning and Evaluation Committee will periodically review the policy for updates.

IV. Purpose of This Policy

This policy outlines the levels of EHR access by training year, expectations for medical student use of the EHR, and expectations for faculty, residents, and educators who are working with medical students in the EHR.

V. Who Should Be Knowledgeable about This Policy

MUSC College of Medicine Faculty, Fellows, Residents, Students, and Educators
Institutional Compliance
Health Informatics Management Committee

VI. The Policy

 

A. General EHR Access and Privileges for Undergraduate Medical Students

This section outlines the specific functions that medical students are allowed to perform in the EHR during both inpatient and outpatient care by their year of training. 

Preclerkship Students

At this level, students have “view only” access. They log in under an ambulatory context in order to view the EHR. Students can use available lists based on service team or unit to pull up a hospital encounter for a patient. They can also search for inpatients in the upper right search box on the “patient lists” screen. Once in the hospital encounter, the students have a summary tab to the left. On the summary screen, print groups are available for vital signs, current medications, and “IP Patient History” which includes past medical, surgical, family, and social history. 

Clinical Students

At this level, students have defined access to entering and editing information.

All student note types automatically populate a “medical student” header that indicates the note is for educational purposes. Student documentation that is “pended” (unsigned by the student) or signed by the student, but not addended and authenticated by a licensed provider, is not a part of the legal medical record.

Access and use vary between the inpatient and ambulatory settings and are outlined below.

Inpatient Setting:

Medical students will have access to the following note types in the inpatient setting:
• Medical Student (cannot be addended or signed by residents or attendings)
• Progress Note
• Consult Note
• H&P
• Code Documentation
• Death Note
• Death Summary
• Discharge Summary
• Seclusion and Restraint Treatment Plan
• Transfer Summary
• Trauma
• Treatment Plan

Within the inpatient context, students can perform the following functions:
• Pend, sign, or cancel a note. Pended notes are only visible to the author. Pended notes in the inpatient context are automatically deleted at patient discharge.
• Enter “smart text” or note templates within their specified note types
• View “shared” notes. Students may not create, edit, or sign “shared” notes with the exception of discharge summaries.
• Place “pended” orders that are seen by/sent to an authorizing provider but not seen by nursing staff until signed by an MD
• Edit and print the handoff

• Access the ADT (admit, discharge, transfer) navigator
• “Share” a discharge summary in progress for signature by a resident and attending as it represents a continuing story about a patient’s hospitalization.

Ambulatory Settings and Emergency Department:

Medical students will have access to the following note types in all ambulatory settings:
• Medical Student Note (cannot be addended or signed by residents or attendings)
• Progress Note

Within the ambulatory visit navigator, students can perform the following functions:
• Enter vital signs
• Enter chief complaint/reason for visit
• Enter history
• Enter allergies
• Review medication reconciliation with patients
• Enter a “medical student” or “progress” note type according to instruction of supervising MD
• Pend, sign or cancel a note. Pended notes are only visible to the author. Students must remove or complete their ambulatory notes before leaving for the day as to avoid preventing closure of the encounter by the teaching physician.
• Enter problems on the problem list under the supervision of MD
• Add visit diagnosis
• Pend (not sign) orders for medications, tests, etc.
• Enter patient instructions and follow up instructions
• Access the outpatient daily clinic schedules and filter these down to a provider level. As long as the student is logged into the correct outpatient clinic context, they can click the “schedule” button at the top and then look at the entire clinic’s schedule or just one provider’s schedule for that day. This allows the student to select and open the charts of the patients they will see in clinic without having to manually search for the patient.
• Preview and print the After Visit Summary (AVS). The AVS should not be printed until documentation is reviewed by the supervising MD and the patient is ready to leave as the patient takes home the AVS to document medications, labs, plans, etc. regarding their care.

All students, years one through four, have “view only” access in the Haiku and Canto applications.


B. Expectations for Students, Residents, Faculty, and Educators

This section outlines educational, ethical, and compliance standards that are expected by multiple parties involved in student use of the EHR.

Students in the Clinical Years

• Will only document under their personal network credentials (username and password).
• Will not copy and paste from another person’s note.
• Notes should be entered in the EHR. If a student has occasion to enter medical information into another system for educational purposes, only MUSC approved systems (ex. Box) may be used in order to ensure the privacy of patient information.
• The use of templates will be decided by individual clerkships and departments. The use of no template or approved templates is intended to facilitate documentation efficiency while promoting development of fundamental documentation skills and clinical reasoning.
• Will seek feedback on their notes from resident and attending physicians.

Residents/Attendings

• Will only document under their personal network credentials (username and password).
• Will ask students to enter their notes only in the EHR (not word processing programs, google docs, etc.) in order to ensure the privacy of patient information.
• Will follow compliance guidelines when editing student documentation for billing. Student documentation must always be edited to reflect the personal collection or verification of history and physical exam as well as medical decision-making of the resident and/or attending.
• Should remove the “medical student” header when they addend and sign medical student documentation.
• Should always add an attestation when using student documentation to reflect the resident or attending’s involvement. Attestations can be added by the resident and attending in succession.
• Do not have co-sign requirements for any note type available to medical students.
• May edit and sign a discharge summary shared by a medical student.
• Are encouraged to provide feedback to students on their documentation.

Educators

• Clerkships will provide students with orientation materials related to expectations around documentation in the EHR and approved templates at the beginning of each clerkship rotation.

VII. Special situations

MUSC COM students who are working in other EHR systems (ex. on rural or community clinical rotations) should abide by any access and use guidelines for that system, which may differ from our MUSC access levels. The general expectations outlined in section VI.B would still apply in outside settings as well. 

VIII. Sanctions for Non-compliance

If a student is found to be noncompliant with this policy, a physicianship form will be completed and submitted to the Dean’s Office. This may result in review by the Progress Committee. For residents and faculty members who are not compliant with this policy, notification will be provided to their program directors or department chairs. Additional sanctions may be applied if the noncompliance also represents an infraction of institutional policy or local, state, or federal laws.

 

IX. Related Information

 

A. References, citations

[1] Colleges AoAM. Allowing Student Documentation in the Electronic Health Record. Compliance Advisory: Electronic Health Records (EHRs) in Academic Health Centers. 2014:1-6.

[2] Hammoud MM, Dalymple JL, Christner JG, et al. Medical student documentation in electronic health records: a collaborative statement from the Alliance for Clinical Education. Teach Learn Med. 2012;24:257-66.

B. Appendices

Appendix A. Quick Reference Summary Chart

X. Communication Plan

• Incorporate a summary chart to disseminate with the policy. This may serve as a “quick reference” for educators and clinicians.
• Incorporate the policy into Epic curricula for new students, residents, and physicians.
• Work with the Senior Associate Dean for Graduate Medical Education and the GME office to educate residents about the policy.
• Include the policy in each clerkship syllabus so students are repeatedly made aware of what they are able to do in the EHR.
• Email policy to students and/or require that students complete an attestation in Moodle or MyQuest.

Policy located at: College of Medicine Policies and Procedures

XI. Definitions

N/A

XVI. Review Cycle

Policy will be reviewed every 2 years.

XVI. Approval History

List original approval date and subsequent review dates

Approval Authority  Date Approved

College of Medicine Undergraduate Curriculum Committee: June 14, 2019

College of Medicine Undergraduate Curriculum Committee:  July 20, 2018

College of Medicine Clinical Sciences Planning and Evaluation Committee:  July 11, 2018

College of Medicine Undergraduate Curriculum Committee:  May 5, 2017

Health Informatics Management Committee, Legal and Institutional Compliance: February 16, 2017

College of Medicine Undergraduate Curriculum Committee:  January 20, 2017

College of Medicine Clinical Sciences Planning and Evaluation Committee:  January 11, 2017

COM Committee on Student Access and Use in the EHR:  December 9, 2016

 

XVII. Approval Signature

  June 14, 2019

  Donna Kern, MD  Date
Title: Senior Associate Dean for Medical Education, College of Medicine